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PERMITTEE NAMEIADDRESS Uncfude Farik.0'aredracad- if Dffferrnfr <br />NAME <br />ADDRESS <br />BUK 67U <br />-EN CIO BI63 <br />FACILITY <br />ACA 1`;IP4F ?01"'1=LrX <br />LOCATION CC) 8163 <br />f KAREL RECLAMATION MANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEA MO DAY <br />FROM TO <br />Form ApPlaved. <br />OMB No. 2040-0004 <br />MINOR <br />(E;UBR JC <br />F-- rINAi <br />DISCHARG] <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> OF <br />T <br />E <br /> EX ANALYSES YP <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEAS <br />N <br /> UREME <br />T -- J <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />` <br /> MEASUREMENT -1i <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br />? <br /> .- <br />? f. .- . <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />A <br />R <br /> ME <br />SU <br />EMENT V <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 rertir% under penalti of Ian that thts document and all attachment% were <br />d <br />d <br />di TELEPHONE DATE <br /> prepare <br />un <br />er my <br />rection or wpenision in accordance with a cystren designed <br /> to awwre that tryalified penonnrl pr,)Wrl% Rather and realuate the inforntatiwt <br /> suhmitted. Based tm my inquin #A the penon ar persom who manage the system. <br />r <br /> or thuse Pete, diredi? respumittle for gathering the Information, the information ' r <br /> <br />suhmilted f%, to the best of my know ledge and Ixlirf, true. accurate. and complete. I <br /> I am aware that there are si <br />nificant <br />enalties for s <br />b <br />itti <br />f <br />ls <br />i <br />fo <br />ti SIGNAT E OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED g <br />p <br />u <br />m <br />ng <br />a <br />e <br />n <br />rma <br />on. <br />including the p„ssibility of rant and impriv nment for konwing •iolatiom. OFFI R OR AUTHORIZED AGENT A <br /> <br />REA NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MQ <br /> <br />DAY <br />k.VMMCIYI Zt ANU CAYLAIYAI IVN Ur' ANT VIVLAIIVIVD (rrererence an arracnmenrs nere) <br />YMT-r AQP" TFT? Fnp ^-e 24HR PRF("rra Fl,"•I•17- 7??. <br />PAGE OF <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. Th1S_IS r'Y•4-part f617[l.